Health Care Options 2012-2013 - Department of Budget and Management

Health Care Options 2012-2013

B State of Maryland — Health Care Options 2012-2013

take steps to live well, exercise regularly and eat well. And see your

primary care doctor early enough to catch problems when they are most treatable.

, who knows you best, understands how to keep you well, and

if you get sick, can get you back on the road to good health.

, there when you need us most. And there every day encouraging

a healthy lifestyle and an active relationship with your primary care doctor.

Welcome to a healthy relationship. One where everyone is committed to keeping you healthy.

State of Maryland — Health Care Options 2012-2013 1

WelcomeWelcome to your plan for healthy living.

We know how important prevention, healthy living, early detection

and early treatment are to you. It’s one of the many advantages of

having CareFirst BlueCross BlueShield. We will work with you to help

you maintain a healthy lifestyle, prevent illness and seek care when

you need it.

We want to thank you for choosing a CareFirst health plan because we

know that health insurance is one of the most important decisions you can

make for you and your family. This guide will help you understand your

plan benefits and the resources available to you as a CareFirst member.

Please keep this guide – the information will be useful to you as long

as you are enrolled in this plan.

How Your Plan WorksFind out how your health plan works and how you can access the

highest level of coverage.

What’s CoveredSee how your benefits are paid, including any deductibles, copayments

or coinsurance amounts that may apply to your plan.

Getting the Most out of Your PlanTake advantage of the added features you have as a CareFirst member:

n Options discount program offering discounts for alternative

therapies, gym memberships, weight loss and hearing care.

n Online access to quickly find a doctor or search for benefits and

claims.

n My Care First wellness website with health calculators, tracking

tools and podcast videos on specific health topics.

n Vitality magazine with healthy recipes, preventive health care tips,

and articles on nutrition, physical fitness, and stress management.

ABC

ABC

ABC

New! Symptom Checker iPhone App

n Find out when you can manage symptoms at home and when to seek medical care.

n Locate the nearest emergency room and urgent care facility.

n Look up the prescribed dosage of common over-the-counter medicines for children.

n And more!

2 State of Maryland — Health Care Options 2012-2013

n POS members no longer need referrals to receive care from an

in-network Specialist.

n New ID cards will be issued to all members regardless of

product.

n $30 copayments for Specialists and Urgent Care Centers.

n $75 copayment for Emergency Room facility plus $75 Emergency

Room physician.

n No change to Primary Care Provider copayment.

n PPO and POS plans pay 90% of allowed benefit in-network

and 70% of allowed benefit out-of-network for services not

associated with a copayment.

n Annual out-of-pocket maximums added to in-network services

to protect you from financial hardship (see enclosed Benefit Chart

for details).

What’s Happening Effective 7/1/2012?


State of Maryland Customer Service

(800) 225-0131

TTY: Maryland Only — 711 Outside Maryland — (800) 735-2258

Owings Mills(Walk-in service only)

Monday – Friday 8:30 a.m. – 4:30 p.m.10802 Red Run Blvd.Owings Mills, MD 21117

Annapolis District Office Monday – Friday 8:30 a.m. – 4:30 p.m.151 West Street, Suite 101Annapolis, MD 21401(410) 268-6488

Cumberland District Office Monday – Friday 8:30 a.m. – 4:30 p.m.10 Commerce DriveCumberland, MD 21502(301) 724-1313(301) 245-4215 (Oakland extension)

Easton District Office Monday – Friday 8:30 a.m. – 4:30 p.m.301 Bay Street, Suite 401Easton, MD 21601(410) 822-1850

Frederick District Office Monday – Friday 8:30 a.m. – 4:30 p.m.110 Baughman’s Lane, Suite 100Frederick, MD 21702(301) 663-3138

Hagerstown District Office Monday – Friday 8:30 a.m. – 4:30 p.m.182 – 184 Eastern Blvd.Hagerstown, MD 21740(301) 733-5995

Salisbury District Office Monday – Friday 8:30 a.m. – 4:30 p.m.224 Phillip Morris Drive, Suite 106Salisbury, MD 21804(410) 742-3274

Important Phone Numbers


Preferred Provider Organization (PPO)

No referrals. No PCPs.

Coverage anywhere.

Benefits of PPOn Access to our network of more than 23,000 doctors, specialists and

hospitals in Maryland, Washington, D.C. and Northern Virginia.

n Enjoy the freedom to visit providers outside of the PPO network

and still be covered but with a higher out-of-pocket cost.

n No primary care provider required, and no referrals to see a

specialist.

n Take your health care benefits with you — across the country

and around the world.

n No copay for in-network preventive visits.

Designed for today’s health conscious and busy families, the

Preferred Provider Organization (PPO) plan offers one less thing

to worry about during your busy day. Your PPO plan gives you

the freedom to visit any provider you wish – any time you wish.

This means you can receive care from the provider of your choice

without ever needing to select a primary care provider (PCP) or

obtaining a PCP referral for specialist care.


Preferred Provider Organization (PPO)

How Your Plan WorksIn-network vs. Out-of-network CoverageThe amount of coverage your PPO plan offers depends

on whether you see a provider in the PPO network.

You will always receive a higher level of benefits when

you visit a preferred provider. However, the choice is

entirely yours. That’s the advantage of a PPO plan.

In-network benefits provide a higher level of coverage.

This means you have lower out-of-pocket costs when

you choose a preferred provider. If you are out of the

CareFirst BlueCross BlueShield (CareFirst) service

area, you have the freedom to select any provider

that participates with a Blue Cross and Blue Shield

PPO plan across the country and receive benefits at

the in-network level.

Out-of-network benefits provide a lower level of

coverage in exchange for the freedom to seek care

from any provider you choose. If you receive services

from a provider outside of the PPO network (non-

preferred provider), you may have to:

n Pay the provider’s actual charge at the time you

receive care.

n File a claim for reimbursement.

n Satisfy a higher deductible and/or coinsurance

amount.

Hospital Authorization/ Utilization Management

Preferred providers will obtain any necessary

admission authorizations for in-area covered services.

You will be responsible for obtaining authorization for

services provided by non-preferred providers and out-

of-area admissions. Call toll-free at (866) 773-2884.

Out-of-Area CoverageYou have the freedom to take your health care

benefits with you – across the country and around

the world. BlueCard® PPO, a program from the

Blue Cross and Blue Shield Association, allows

you to receive the same health care benefits when

receiving care from a BlueCard® preferred provider

while living or traveling outside of the CareFirst

service area (Maryland, Washington, D.C. and

Northern Virginia). The BlueCard® program includes

more than 6,100 hospitals and 600,000 other health

care providers nationally.


At CareFirst BlueCross BlueShield, we aim to keep you healthy

by emphasizing prevention, healthy living, early detection and

early treatment. That’s one of the main advantages of having

CareFirst BlueCross BlueShield coverage. We work with you to

help prevent illness and we encourage you to seek care when

it is needed.

Exclusive Provider Organization (EPO)

Benefits of EPOn EPO offers you the features of a PPO with in-network benefits

only.

n Access to our network of more than 23,000 doctors, specialists

and hospitals in Maryland, Washington, D.C. and Northern

Virginia.

n No primary care provider required, and no referrals to see a

specialist.

n Take your health care benefits with you — across the country

and around the world.

n No copay for in-network preventive visits.


Exclusive Provider Organization (EPO)

The Benefits You NeedAs a participant in the EPO plan, we cover you and your

family for medically necessary health care. Whether

you need routine or specialty service, you will need to

visit a participating provider in order to receive care.

Preventive care is covered at 100% with no copayment

when rendered by an in-network provider.

Behavioral Health TreatmentMagellan Behavioral Health Services provides and

coordinates all needed behavioral health care. Just

call their toll free number at (800) 245-7013 for a

referral and authorization if you need psychiatric or

substance abuse treatment.

Comprehensive benefitsWith EPO, you not only have the strength of Blue Cross

and Blue Shield Plans credentialed network providers,

but a wide range of benefits including immunizations,

office visits, routine gynecological visits and well-child

care. Other preventive services such as diagnostic

tests, and mammography screenings can help you

treat conditions before they become serious.

Emergency CareEach CareFirst doctor provides 24-hour-a-day availability

so you are never out of reach of your doctor. If the

condition is serious, but not life threatening, call your

doctor and he or she will give you instructions on what

to do next.

Service That CountsYou can talk to knowledgeable Customer Service

representatives who will be happy to answer any

questions you may have about claims and benefits.

When You Need CareOnce you have enrolled in the EPO and your benefits

are effective, you are ready to use your health

insurance plan. Whether you need routine care or

specialty care, you will need to visit a participating

PPO provider in order to receive coverage. Please

log on to www.carefirst.com/statemd to find a

participating provider.

If you choose to go to a physician other than a

participating PPO provider, benefits will not be

provided for care you have received.


Point of Service® (POS)Now without referrals — Effective 7/1/2012

Benefits of POSn No referrals to receive care from an in-network Specialist

effective 7/1/2012.

n Access our network of more than 23,000 doctors, specialists and

hospitals in Maryland, Washington, D.C. and Northern Virginia.

n Your care is coordinated through a Primary Care Provider who

knows you and can assist you with your overall health care

concerns.

n No copays for in-network preventive visits.

You can select your doctor from a network of physicians, specialists

and hospitals located throughout Maryland, Washington, D.C. and

Northern Virginia – so now you can visit a doctor where you live,

where you work or anywhere in between. Designed for today’s

health conscious and busy families, Point of Service offers one

less thing to worry about during your busy day.

Point of Service aims to keep you healthy by emphasizing

prevention, early detection and early treatment. That’s one of

the main advantages of your POS coverage. We work with you to

help prevent illness and we encourage you to seek care when it

is needed, rather than waiting.

Point of Service (POS) offers two levels of benefits in one health

plan. When you need medical care, you have the flexibility to

see your primary care provider (PCP) or Specialist within your

network now with no referrals, or you can choose to go “out

of the network” and see any doctor you choose. Your choice

determines whether benefits will be paid at the in-network or

out-of-network level.

Coordinated care with the freedom to choose.


Point of Service® (POS)Now without referrals — Effective 7/1/2012

Maternity and Well-Child CarePOS provides coverage for prenatal and postnatal

visits. Childhood immunizations and check-ups are

covered at 100% with no copayment when services are

provided by your PCP.

When you enroll in Great Beginnings, one of our case

managers will contact you to review your medical

history and identify any conditions that may affect

your pregnancy. The case manager will provide

education and information on prenatal care and

pregnancy, along with information on community

resources and support groups. They’ll also give you

their contact information, so in the event a problem

occurs, you may contact them.

If complications occur during your pregnancy, a

case manager will work closely with you and your

doctor(s) to coordinate any necessary services. Your

case manager will contact you as often as necessary

to provide optimal care coordination and support,

along with any other information you may need.

To enroll in Great Beginnings or find out more

information about our program, call 888-264-8648.

Emergency and Urgent CareEach POS doctor provides 24-hour-a-day availability

so you are never out of reach of your PCP. If the

condition is serious, but not life threatening, call your

PCP and he or she will give you instructions on what

to do next.

Your doctor may refer you to an urgent care center.

Urgent care centers are walk-in medical facilities

equipped to handle minor emergencies. Urgent

care centers allow you to be seen more quickly

than emergency rooms and most have evening and

weekend hours. A list of participating urgent care

centers can be found in the provider directory or at

www.carefirst.com/statemd, “Find a Doctor.”

In a life-threatening emergency, such as chest pain,

unconsciousness or severe bleeding, we encourage

you to go immediately to the nearest emergency

room or call 911.

Your Primary Care Provider (PCP)Establishing a relationship with one PCP (physician

or nurse practitioner) is the best way for you to

receive consistent, quality health care; therefore,

you must select a PCP at the time of your enrollment

into POS. It is important that you select a PCP. If you

have not selected a PCP for yourself or a covered

family member, all covered services will be covered

at the out-of-network level.

Your PCP will:

n Provide basic medical care — treating illness and

providing preventive care.

n Prescribe any medications that you may require.

n Maintain your medical history.

n Work with you to determine when you should see

a specialist, assist in the selection of a specialist.

You may choose a doctor or nurse practitioner who

specializes in family practice, general practice,

pediatrics or internal medicine as your PCP. Your

entire family may select the same provider, or each

member may choose a different provider, based on

each person’s age or medical needs.

If you are a new enrollee, complete a PCP selection

form by logging on to www.carefirst.com/statemd,

“Forms” and print out a PCP selection form, or

call customer service at (800) 225-0131. If you are

currently enrolled and want to change your PCP, log on

to www.carefirst.com/statemd, “My Account” to make

your change electronically.


Benefits At-a-GlanceBenefits PPO - Preferred Provider Option POS - Point of Service

CareFirst EPOBenefit Period - 7/1/2012 - 6/30/2013 In-Network Out-of-Network In-Network Out-of-Network

DeDuctible $0 $250 individual/$500 family $0 $250 Individual/$500 family $0

Out-Of-POcket limit $1,000 individual/$2,000 family $3,000 individual/$6,000 family $1,000 individual/$2,000 family $3,000 individual/$6,000 family $0

lifetime mAximum None None None

inPAtient HOsPitAl/fAcility services(Preauthorization required)

Room & Board (includes maternity) 365 days of coverage (other special care units), and Ancillary Services (includes nursery charges)

90% of Allowed Benefit 70% of Allowed Benefit after deductible; 90% after emergency admission

90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Organ Transplants(Preauthorization required)

90% of Allowed Benefit for cornea, kidney, bone marrow, heart, heart-lung, single or double lung, liver and pancreas

70% of Allowed Benefit after deductible for cornea, kidney, bone marrow, heart, heart-lung, single or double lung, liver and pancreas




Extended Care Facility (ECF) - 180 days per Benefit Period (Preauthorization required)

90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Hospice Care(inpatient or at home; Preauthorization required)

90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 90% of Allowed Benefit 100% of Allowed Benefit

inPAtient PrOfessiOnAl/PrActitiOner services

Physician Surgical Services 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Anesthesia 90% of Allowed Benefit 90% of Allowed Benefit 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Consultations (including follow-visits) & Physician Visits (includes ECF)


Radiation Therapy, Chemotherapy, and Renal Dialysis 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

OutPAtient HOsPitAl/fAcility services

Emergency Room Facility Services- Inside and outside the service area (Note: Separate copay from ER Physician)

$75 copay. Copay waived if admitted. If criteria are not met for a medical emergency, or accidental injury, plan coverage is 50% of allowable benefit plus $75 copay.



Emergency Room Physician Services- Inside and outside the service area (Note: Separate copay from ER facility)




Cardiac Rehabilitation (Outpatient Freestanding Clinic or Outpatient Hospital only, 36 sessions in 12-week period with physician supervision and in medical facility; medical necessity with physician authorization and history of heart attack in past 12 months, CABG surgery, angioplasty, heart valve surgery, heart transplant, stable angina pectoris, compensated heart failure.)

90% of Allowed Benefit 70% of Allowed Benefit; after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Home Health Care (120 days per Benefit Period) 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Minor/All Surgery (includes hospital based and freestanding surgical centers)


Preadmission Testing 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Diagnostic Tests (includes X-rays, machine tests, pathology, CAT scans, MRIs, and Holter Monitors)


OutPAtient/Office PrOfessiOnAl services

Physician Office Visit - Primary Care $15 copay 70% of Allowed Benefit after deductible $15 copay 70% of Allowed Benefit after deductible $15 copay

Physician Office Visit - Specialist $30 copay 70% of Allowed Benefit after deductible $30 copay 70% of Allowed Benefit after deductible $30 copay

Urgent Care Centers $30 copay 70% of Allowed Benefit after deductible $30 copay 70% of Allowed Benefit after deductible $30 copay

Minor/All Surgery 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

AB (Allowed Benefit): The maximum dollar amount allowed for services covered, regardless of the provider’s actual charge.


Benefits At-a-GlanceBenefits PPO - Preferred Provider Option POS - Point of Service

CareFirst EPOBenefit Period - 7/1/2012 - 6/30/2013 In-Network Out-of-Network In-Network Out-of-Network

DeDuctible $0 $250 individual/$500 family $0 $250 Individual/$500 family $0

Out-Of-POcket limit $1,000 individual/$2,000 family $3,000 individual/$6,000 family $1,000 individual/$2,000 family $3,000 individual/$6,000 family $0

lifetime mAximum None None None

inPAtient HOsPitAl/fAcility services(Preauthorization required)

Room & Board (includes maternity) 365 days of coverage (other special care units), and Ancillary Services (includes nursery charges)

90% of Allowed Benefit 70% of Allowed Benefit after deductible; 90% after emergency admission

90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Organ Transplants(Preauthorization required)






Extended Care Facility (ECF) - 180 days per Benefit Period (Preauthorization required)


Hospice Care(inpatient or at home; Preauthorization required)


inPAtient PrOfessiOnAl/PrActitiOner services

Physician Surgical Services 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit


Consultations (including follow-visits) & Physician Visits (includes ECF)


Radiation Therapy, Chemotherapy, and Renal Dialysis 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

OutPAtient HOsPitAl/fAcility services

Emergency Room Facility Services- Inside and outside the service area (Note: Separate copay from ER Physician)




Emergency Room Physician Services- Inside and outside the service area (Note: Separate copay from ER facility)




Cardiac Rehabilitation (Outpatient Freestanding Clinic or Outpatient Hospital only, 36 sessions in 12-week period with physician supervision and in medical facility; medical necessity with physician authorization and history of heart attack in past 12 months, CABG surgery, angioplasty, heart valve surgery, heart transplant, stable angina pectoris, compensated heart failure.)

90% of Allowed Benefit 70% of Allowed Benefit; after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Home Health Care (120 days per Benefit Period) 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Minor/All Surgery (includes hospital based and freestanding surgical centers)


Preadmission Testing 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Diagnostic Tests (includes X-rays, machine tests, pathology, CAT scans, MRIs, and Holter Monitors)



Physician Office Visit - Primary Care $15 copay 70% of Allowed Benefit after deductible $15 copay 70% of Allowed Benefit after deductible $15 copay

Physician Office Visit - Specialist $30 copay 70% of Allowed Benefit after deductible $30 copay 70% of Allowed Benefit after deductible $30 copay

Urgent Care Centers $30 copay 70% of Allowed Benefit after deductible $30 copay 70% of Allowed Benefit after deductible $30 copay

Minor/All Surgery 90% of Allowed Benefit 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

This chart is a general summary of benefits and does not guarantee coverage. Please contact Customer Service or refer to www.carefirst.com/statemd after the Open Enrollment for on-line PPO, POS and EPO group benefit booklets or Evidence of Coverage with plan details.


Benefits PPO - Preferred Provider Option POS - Point of ServiceCareFirst EPO

Benefit Period - 7/1/2012 - 6/30/2013 In-Network Out-of-Network In-Network Out-of-Network



Allergy testing and Injections(copay applies to testing only)

90% of Allowed Benefit after $15 copay (PCP) 90% of Allowed Benefit after $30 copay (Specialist)

70% of Allowed Benefit after deductible 90% of Allowed Benefit after $15 copay (PCP); 90% of Allowed Benefit after $30 copay (Specialist)

70% of Allowed Benefit after deductible 100% of Allowed Benefit after $15 copay (PCP) 100% of Allowed Benefit after $30 copay (Specialist)

X-rays, machine tests and pathology, CAT SCANS, MRIs, and Holter Monitors (physician interpretation of results)


Physical Therapy, Occupational Therapy and Speech Therapy

$30 copay; up to 50 visits per year when combined with Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit.

70% after deductible; up to 50 visits per year when combined with Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. Note: Contact health plan if Speech Therapy provided due to catastrophic illness for consideration of additional visits.

$30 copay up to 50 visits per year when combined with Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. Note: Contact health plan if Speech Therapy provided due to catastrophic illness for consideration of additional visits.


100% after $30 copay; up to 50 visits per year when combined with Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. Note: Contact health plan if Speech Therapy provided due to catastrophic illness for consideration of additional visits.

Hearing Exams and Hearing Aids(Includes Hearing Aid Mandate for minor children)

$15 copay; 100% of plan allowance per device, per ear, every 36 months. Member may be balance billed.

70% after deductible; 100% of plan allowance per device, per ear, every 36 months. Member may be balance billed.


Not covered except for hearing aids as mandated for minor children (ages 0-18)

100% after $15 copay; 100% of plan allowance per device, per ear, every 36 months. Member may be balance billed.

Chiropractic and Acupuncture Pain Management 90% of Allowed Benefit after $20 copay 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit when preauthorized

In Vitro Fertilization (IVF) and Artificial Insemination (AI)(Preauthorization required) For further details on pre-authorization requirements please call our Member Services (Only covered for married couples as recognized by Maryland Law.)

90% of Allowed Benefit 70% after deductible 90% of Allowed Benefit 70% after deductible 100% of Allowed Benefit ( Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime. The 3 IVF attempts per live birth coverage will not exceed a maximum of $100,000 per lifetime. The AI attempts must be taken, when appropriate before IVF attempts will be covered.)

Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime.The 3 IVF attempts per live birth coverage will not exceed a maximum of $100,000 per lifetime.The AI attempts must be taken, when appropriate before IVF attempts will be covered.

Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime. The 3 IVF attempts per live birth coverage will not exceed a maximum of $100,000 per lifetime.The AI attempts must be taken, when appropriate before IVF attempts will be covered.

Preventive/Well cAre (rOutine)

Well Baby/Child Visits (0 through 21 years)(0 – 36 months, up to 12 visits;3 years — 21 years, 1 visit per plan year)

100% of Allowed Benefit 70% after deductible 100% of Allowed Benefit Not covered 100% of Allowed Benefit

Immunizations for adults and children as recommended by the Centers for Disease Control, U.S. Task Force of Preventive Care, and American Academy of Pediatrics including Lyme Disease, but excluding recommendations for travelers.


Annual Adult Physicals (22+ years) 1 per plan year 100% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit Not covered 100% of Allowed Benefit

Annual GYN Services (includes pap) 100% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Nutritional Counseling and Health Education for Chronic Disease (contact CareFirst for more information)


Routine Mammography Screening(One baseline screening for ages 35-39 years.One screening every year 40+.)

100% of Allowed Benefit 70% of Allowed Benefit 100% of Allowed Benefit 90% of Allowed Benefit 100% of Allowed Benefit

rOutine visiOn See Vision Insert See Vision Insert

beHAviOrAl HeAltH

Not covered under Medical Plan. Refer to your 2012/2013 Guide to Your Health Benefits booklet provided by the Employee Benefits Division.


(Behavioral Health benefits administered through Magellan Health Services.) Inpatient: 100% when preauthorized by plan; Outpatient: PCP: 100% of Allowed Benefit after $15 copay

PrescriPtiOn Drugs Not covered

rOutine DentAl Not covered

AB (Allowed Benefit): The maximum dollar amount allowed for services covered, regardless of the provider’s actual charge.

Benefits At-a-Glance


Benefits PPO - Preferred Provider Option POS - Point of ServiceCareFirst EPO

Benefit Period - 7/1/2012 - 6/30/2013 In-Network Out-of-Network In-Network Out-of-Network



Allergy testing and Injections(copay applies to testing only)

90% of Allowed Benefit after $15 copay (PCP) 90% of Allowed Benefit after $30 copay (Specialist)

70% of Allowed Benefit after deductible 90% of Allowed Benefit after $15 copay (PCP); 90% of Allowed Benefit after $30 copay (Specialist)

70% of Allowed Benefit after deductible 100% of Allowed Benefit after $15 copay (PCP) 100% of Allowed Benefit after $30 copay (Specialist)

X-rays, machine tests and pathology, CAT SCANS, MRIs, and Holter Monitors (physician interpretation of results)


Physical Therapy, Occupational Therapy and Speech Therapy

$30 copay; up to 50 visits per year when combined with Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit.


$30 copay up to 50 visits per year when combined with Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. Note: Contact health plan if Speech Therapy provided due to catastrophic illness for consideration of additional visits.


100% after $30 copay; up to 50 visits per year when combined with Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. Note: Contact health plan if Speech Therapy provided due to catastrophic illness for consideration of additional visits.

Hearing Exams and Hearing Aids(Includes Hearing Aid Mandate for minor children)


70% after deductible; 100% of plan allowance per device, per ear, every 36 months. Member may be balance billed.


Not covered except for hearing aids as mandated for minor children (ages 0-18)

100% after $15 copay; 100% of plan allowance per device, per ear, every 36 months. Member may be balance billed.

Chiropractic and Acupuncture Pain Management 90% of Allowed Benefit after $20 copay 70% of Allowed Benefit after deductible 90% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit when preauthorized

In Vitro Fertilization (IVF) and Artificial Insemination (AI)(Preauthorization required) For further details on pre-authorization requirements please call our Member Services (Only covered for married couples as recognized by Maryland Law.)

90% of Allowed Benefit 70% after deductible 90% of Allowed Benefit 70% after deductible 100% of Allowed Benefit ( Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime. The 3 IVF attempts per live birth coverage will not exceed a maximum of $100,000 per lifetime. The AI attempts must be taken, when appropriate before IVF attempts will be covered.)

Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime.The 3 IVF attempts per live birth coverage will not exceed a maximum of $100,000 per lifetime.The AI attempts must be taken, when appropriate before IVF attempts will be covered.

Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime. The 3 IVF attempts per live birth coverage will not exceed a maximum of $100,000 per lifetime.The AI attempts must be taken, when appropriate before IVF attempts will be covered.

Preventive/Well cAre (rOutine)

Well Baby/Child Visits (0 through 21 years)(0 – 36 months, up to 12 visits;3 years — 21 years, 1 visit per plan year)

100% of Allowed Benefit 70% after deductible 100% of Allowed Benefit Not covered 100% of Allowed Benefit

Immunizations for adults and children as recommended by the Centers for Disease Control, U.S. Task Force of Preventive Care, and American Academy of Pediatrics including Lyme Disease, but excluding recommendations for travelers.


Annual Adult Physicals (22+ years) 1 per plan year 100% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit Not covered 100% of Allowed Benefit

Annual GYN Services (includes pap) 100% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit 70% of Allowed Benefit after deductible 100% of Allowed Benefit

Nutritional Counseling and Health Education for Chronic Disease (contact CareFirst for more information)


Routine Mammography Screening(One baseline screening for ages 35-39 years.One screening every year 40+.)

100% of Allowed Benefit 70% of Allowed Benefit 100% of Allowed Benefit 90% of Allowed Benefit 100% of Allowed Benefit

rOutine visiOn See Vision Insert See Vision Insert

beHAviOrAl HeAltH



(Behavioral Health benefits administered through Magellan Health Services.) Inpatient: 100% when preauthorized by plan; Outpatient: PCP: 100% of Allowed Benefit after $15 copay

PrescriPtiOn Drugs Not covered

rOutine DentAl Not covered

This chart is a general summary of benefits and does not guarantee coverage. Please contact Customer Service or refer to www.carefirst.com/statemd after the Open Enrollment for on-line PPO, POS and EPO group benefit booklets or Evidence of Coverage with plan details.

Benefits At-a-Glance


Vision Plan

Healthy Vision – an Important AssetVision is one of our most valued assets. Everyone

should take precautions to protect this priceless gift.

Some vision problems, such as glaucoma, can only be

detected through regular, professional vision exams.

Without proper care, these problems can gradually

grow worse. Visit the provider of your choice for your

routine vision exam and the plan pays $45.

Mail Order Replacement Contact Lenses

Free membership and access to a mail order

replacement contact lens service, Lens 1-2-3®, provides

a fast and convenient way to purchase replacement

contact lenses at significant savings. For more

information, go to www.Lens123.com.

How the Plan WorksOur Vision plan is as easy to use as it is effective.

You simply show your CareFirst BlueCross BlueShield

membership card to participating providers at the

time of service. The participating provider will bill us

and we pay them directly for their services. You don’t

have any paperwork or claims to file.

If you choose a non-participating provider for your

care, you must pay the provider. We will reimburse

you up to the limits of your vision plan.

Vision Benefit (Benefit Period - 7/1/12 - 6/30/13) Plan Pays

rOutine eye cAre Vision benefits are the same for PPO, POS and EPO members. Plans pay $45 per benefit period toward the exam.

frAmes Plan pays $45 toward one pair of frames per benefit period

PrescriPtiOn lenses (per pair)Available once every benefit period

Single Vision ....................................................$28.80

Bifocal, single ..................................................$48.60

Bifocal, double ................................................$88.20

Trifocal .............................................................$70.20

Aphakic, Glass .................................................$54.00

Aphakic, Plastic ...............................................$126.00

Aphakic, Aspheric............................................$162.00

cOntActs (per pair, in lieu of frames and lenses)Available once per benefit period

Medically necessary ........................................$201.60

Cosmetic ..........................................................$50.40


Plan for Retirees with Medicare

PPO Benefits and ServicesThis Medicare Complementary plan provides

comprehensive medical/surgical benefits to Medicare

recipients. It covers your Medicare deductibles and

coinsurances as well as preventive services: hearing

care, annual mammograms and pap tests. This

CareFirst plan is your secondary coverage to Medicare.

This means that Medicare always pays first and your

CareFirst plan pays as your secondary insurance. All

providers, doctors and hospitals who accept Medicare

assignment have agreed to accept the Medicare

allowed amount as full payment for covered services.

Once Medicare processing is complete you will receive

a copy of the Medicare Explanation of Benefits (EOB)

for your records. Your secondary processing will then

occur automatically, which will generate a CareFirst

EOB that will be sent to you. If a provider does not

accept Medicare assignment the provider will still file

your claim, however any payment of covered services

would be paid directly to the member by Medicare

and CareFirst.

POS Benefits and ServicesPoint of Service (POS) is a Medicare complementary

plan that provides comprehensive medical/surgical

benefits to Medicare recipients. The POS plan

requires that you select a Primary Care Provider

(PCP) who will coordinate your care so that all

services will be covered as in-network. POS covers

your Medicare deductibles and coinsurances. It

also provides valuable benefits for these preventive

services: hearing care, annual mammograms and

pap tests. The CareFirst POS plan is your secondary

coverage to Medicare. This means that Medicare

always pays first and your CareFirst POS plan pays

as your secondary insurance. All providers, doctors

and hospitals who accept Medicare assignment have

agreed to accept the Medicare allowed amount as

full payment for covered services. Once Medicare

processing is complete you will receive a copy of

the Medicare EOB for your records. Your secondary

processing will then occur automatically, which will

generate a CareFirst EOB that will be sent to you.

EPO Benefits and ServicesCareFirst offers this Medicare complementary plan which

provides comprehensive medical/surgical benefits to

Medicare recipients covering your Medicare deductibles

and coinsurances as well as many preventive services

only when services are rendered by a provider who

accepts Medicare. Services rendered by a provider who

does not accept Medicare is considered out-of-network

and not covered. This CareFirst BlueCross BlueShield

plan is your secondary coverage to Medicare meaning

that Medicare always pays first and your CareFirst

BlueCross BlueShield plan pays second. All providers,

doctors and hospitals who accept Medicare assignment

have agreed to accept as full payment the Medicare

allowed amount for covered services. Once Medicare

processing is complete you will receive a copy of the

Medicare Explanation of Benefits (EOB) for your records

and your secondary processing will occur automatically

which will generate a CareFirst BlueCross BlueShield

EOB to you. Note: EPO MEMBERS MUST SEEK SERVICES

FROM A PROVIDER WHO ACCEPTS MEDICARE TO

RECEIVE BENEFITS FOR A COVERED SERVICE.


Patient-Centered Medical HomeFocusing on you and your health

Whether you’re trying to get healthy or stay healthy, you need

the best care available. That’s why the CareFirst BlueCross

BlueShield1 family of health plans has created a program to

improve health care quality and help slow rising health care

costs over time.

Our Patient-Centered Medical Home (PCMH) program focuses

on the relationship between you and your primary care provider

(PCP). It’s designed to provide your PCP—whether it’s a

physician or nurse practitioner—with a more complete view of

your health needs, as well as the care you’re receiving from

other providers. As the leader of your health care team, your

PCP will be able to use this information to better manage and

coordinate your care, a key to better health.

Treating Your Overall HealthThere is simply no one in the health care system better positioned

to coordinate and manage your overall health than your PCP.

Whether you see your PCP for preventive care, or you need more

care, your PCP is expected to:

n Coordinate your care with all your health care providers,

including specialists, labs, pharmacies, and mental health

facilities to help you get access to and receive the most

appropriate care available in the most affordable settings.

n Identify and address any impact the care you receive for one

health issue may have on another.

n Review all of your medications and possible drug interactions

with you.

n Review your health records for duplicate tests or services

already ordered or performed by another provider.

Why a PCP is important to your health.By visiting your PCP for routine visits

as recommended, you can build a

relationship, and your PCP will get to

know you and your medical history.

A PCP is concerned with your overall

health. If you have an urgent health

issue, having a PCP who knows your

health history often makes it easier

and faster to get the care you need.

Your PCP can sometimes provide

advice over the phone or fit you in

for a visit. That helps you avoid long

lines and expensive charges at the

emergency room.

When you visit your PCP for screenings

and preventive services, they can

detect health concerns in the early

stages, when they are easier and less

costly to treat.


Patient-Centered Medical HomeFocusing on you and your health

After reviewing your current health status, your PCP

will determine if you’re eligible for a care plan. If

eligible, you’ll receive a higher level of care, beginning

with a personalized care plan developed by your PCP.

A care plan is an online record that documents

your medical needs and specific actions you should

take to better manage or improve your health. Your

progress will be monitored by a team that includes

your PCP, a care coordinator (a registered nurse) and

other care professionals with the goal of minimizing

your risks and improving your health.

If you have a chronic condition, or are at risk for one,

your PCP may:

n Create a care plan based on your health needs with

specific follow up activities to help you manage

your health.

n Provide access to a care coordinator, who is a

registered nurse (RN), so you have the support you

need, answers to your questions and information

about your care.

If you’re not eligible for a care plan, you’ll continue

to see your PCP for regularly scheduled visits

and benefit from the increased access to care,

preventive care services and engagement with

your PCP.

What is a care coordinator?A care coordinator is a registered nurse who works

with your PCP to coordinate your care and help

you improve your health. Your care coordinator is

expected to:

n Assist your PCP by coordinating your care and

answering your questions.

n Follow up with you to make sure you’re not

having problems following your treatment plan.

For example, if you have diabetes, the care

coordinator can help you take steps to better

understand control your diabetes.

n Assist you in obtaining services and equipment

necessary to manage your health condition.

It’s Your ChoicePCMH is a voluntary program. When you participate:

n You pay no additional premium.

n There is no change in your benefits.

n There is no change to your health plan

requirements.

n You can opt-out at any time without penalty and

without changing your PCP.

Please note that if you have a high deductible health

plan, certain charges may apply until you meet your

deductible.

How Do I Get Started?Simply sign the Authorization and Consent for

Participation form and return it to your PCP.

You can get the form from your PCP, or you can download

it from the Forms section at www.carefirst.com

under the PCMH tab. By signing the consent form,

you agree to give your PCP access to your health

information on file with CareFirst. This includes data

from claims and notes from any CareFirst programs

in which you have participated.


How to Locate a Providerwww.carefirst.com/statemd

1.Go to www.carefirst.com/statemd.

2. Click the “Find a Doctor” tab

on the main page.

3. Choose your health plan

and click “continue”.

If you do not have internet access and

would like to request a copy of a printed

directory, please call the Member

Services phone number listed on your

member ID card.

Find A Doctor


My AccountOnline Access to Your Claims

View real-time information on your claims and out-of-pocket costs online, whenever you need to with My Account. Simply log on to www.carefirst.com/statemd, “My Account” for real-time information about your plan.

Features of My Accountn Request replacement ID card.

n Find out who’s covered on your policy and the

effective date of your coverage.

n Check your deductible and out-of-pocket costs

for your current and previous plan year.

n Review up to one year of medical claims – total

charges, benefits paid, and costs for a specific

date range.

n Download claim forms.

n Email a nurse and receive a secure, online

response within 24 hours.

n Plan for surgeries and other procedures by

comparing outcomes and other quality measures

for nearby hospitals.

n Currently enrolled POS members can change a

PCP selection.

Your SecurityYour log-in information is completely secure. Select

your own User ID and Password, which you can

change at any time. Our staff will never ask you for

your password and to protect your security you’ll

be logged out automatically after 15 minutes of

inactivity.

Signing Up is EasyVisit www.carefirst.com/statemd, “My Account” and

set up your User ID and Password. You’ll just need

information from your member ID card.


FirstHelp™– 24-HoursHealth Care Advice Line (800) 535-9700

How FirstHelp WorksSimply call (800) 535-9700 and a registered nurse will:

n Ask about your symptoms.

n Help you decide on the best source of care.

When to Call FirstHelpFirst, you should call your doctor when you have a health

concern. If you can’t reach your doctor and have questions

about your health, an illness or an urgent medical condition, a

registered FirstHelp nurse is available to answer your questions

and assist you in determining your options.

If you have an emergency and can’t safely wait to speak with

your doctor, call 911 or go to the nearest emergency room.

FirstHelp nurses won’t be able to answer questions about the

following:

n Your benefits and what is covered by your health care plan.

n Information on your claims.

n Pre-authorizations.

If you have questions about your benefits or claims, please

call the Member Services number listed on the back of your

ID card. If you need authorization for a service, please call the

appropriate number listed on the back of your ID card.

Anytime, day or night, you can speak with a FirstHelp nurse.

Registered nurses are available to answer your health care

questions and help guide you to the most appropriate care.


Alternative Therapies & Wellness Services

For details on the health and wellness discounts available

to you, visit www.carefirst.com/options

Enjoy Discounts with Both ProgramsDiscounted products and services include:

n Acupuncture

n Chiropractic care

n Fitness centers

n Fitness footwear and apparel

n Hearing and vision care including laser vision correction

n Massage therapy

n Nutritional counseling

n Personal training

n Spa services

n Sporting and fitness equipment

n Travel

n Weight loss programs

New products and services are added frequently, so visit us

online at www.carefirst.com/options for the latest list.

In addition to your medical benefits, take advantage of the

special offers and discounts available to CareFirst BlueCross

BlueShield and CareFirst BlueChoice, Inc. (collectively,

CareFirst) members. Our Options and Blue365 discount

programs offer the health and wellness information, support

and services you need — while at the same time providing

you with special member savings.


Health and Wellness DiscountsAlternative Therapies and Wellness Services

The Options and Blue365 programs are not offered as an inducement to purchase a policy of insurance from CareFirst. CareFirst does not underwrite these

programs because they are not insurance products. No benefits are paid by CareFirst under these programs.

Options Program Directory

Alternative Therapies & Wellness

Up to 30% discounts on chiropractic care, acupuncture, massage therapy, nutritional counseling, personal training, yoga, guided imagery, spa services and more.

Healthways WholeHealth Networks, Inc. (800) 514-6502 http://options.wholehealthmd.com

Eldercare Services

Free referral services to help members find qualified providers through ElderCarelink. You can find information for elders and families including home health care, home support, assisted living, adult day care, long term care, nursing homes, and support groups for caregivers.

ElderCarelink (866) 451-5577 www.eldercarelink.com/carefirst

SeniorLink Care (866) 797-2341

Financial Services

Successfully manage your health care costs while maintaining a healthy financial future.

Fitness Apparel and Gear

Exclusive discount on fitness apparel and workout gear.

Fitness Centers

Discounts on membership fees, initiation fees and more depending on which fitness network and location you choose.

Healthways WholeHealth Networks, Inc. (800) 514-6502 http://options.wholehealthmd.com

Anytime Fitness (888) 827-9262

Snap Fitness (877) 474-5422

Hearing Care Free screenings, discounts on hearing aids and more.

Beltone (888) 896-2365 www.carefirst.com/options

TruHearing (877) 343-0745 www.carefirst.com/options

Laser Vision Correction & Contact Lenses*

Discounts on laser vision correction and 100% patient financing with approved credit.

QualSight LASIK (877) 285-2010 www.qualsight.com/–carefirst

LasikPlus (866) 713-2044

TruVision (800) 398-7075 www.truvision.com/carefirst/LASIK.htm *Also offers discounts on mail-order contact lenses

Medical IDs22% discount on personalized medical ID bracelets and necklaces.

American Medical ID (800) 363-5985 www.americanmedical-id.com/extras/carefirst.php

Recreation and Travel

Enjoy savings on travel and leisure expenses.

Fairmount Hotels and Resorts (866) 840-8114

Weight Loss & Management

Nationally recognized weight loss plan discounts.

Jenny Craig® (800) 96-JENNY www.carefirst.com/options

Dole (800) 356-3111

Sportline (866) 324-4438 Everlast (866) 324-4438 Polar (866) 451-5577

H&R Block www.carefirst.com/options

Experianwww.carefirst.com/options


NOTES:


NOTES:

CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and an independent licensee of the Blue Cross and Blue Shield Association. ® Registered trademark

of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

10455 Mill Run Circle

Owings Mills, MD 21117

BOK5314-1S (3/12)

www.carefirst.com/statemd

Documents

Health Care Options 2012-2013 - Department of Budget and Management